**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 7 residents reviewed for admission physician orders. (Resident #93) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 02/12/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on the process of carrying out orders for residents admitted with wounds or obtaining orders if no orders accompanied the resident, completion of weekly skin assessments, wound care orders, skin management policy, and pressure ulcer prevention and interventions for residents with pressure ulcers. These failures could place residents at risk of not receiving appropriate care and treatment services. Findings included: 1. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), morbid obesity (is a medical condition characterized by excessive body weight that significantly impacts health and well-being), and pressure ulcer of right hip, left hip, and other sites, stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed). Record review of the MDS, on 02/10/25, indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit. Record review of Resident #93's care plan dated 02/03/25 indicated: *Resident #93 was admitted with stage 3 pressure ulcer to right thigh. Interventions included assess and document skin condition every week, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with Stage 3 pressure ulcer to right hip. Interventions included assess and document skin condition every week, monitor nutritional intake, weight, lab values and report significant changes to MD, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with stage 3 pressure ulcer to left thigh. Intervention included administer treatments as ordered and monitor for effectiveness, monitor nutritional status, and obtain and monitor lab/diagnostic work as ordered. Record review of Resident #93's consolidated physician orders dated active as of 02/11/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. The consolidated physician order did not reflect wound care orders for Resident #93's left thigh, right hip, and right thigh pressure ulcer on admission [DATE]). Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/02/25. Discontinued 02/09/25. No documentation was noted on 02/02/25 and 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. Record review of Resident #93's progress note dated 01/12/25-02/12/25 indicated: *02/01/25 at 7:47 p.m. by the ADCO, .new admission skin assessment .the following areas were all noted upon admission to the facility . Right Lateral thigh shearing 2cm x 5cm x0.1cm open area without exudate with surrounding scaring . Right gluteal area shearing 0.4cm x 0.4cm x 0.1 cm no exudate noted . Right lateral hip shearing with surrounding scaring 5.5cm x 1.4cm x 0.1cm no exudate noted . Right Posterior hip shearing 1.3cm x 0.9cm x 0.1cm no exudate noted . Right posterior thigh near gluteal fold 1.2cm x 0.1cm. Area is a hard area that appears to be healing . Left posterior thigh shearing 1.2cm x 1cm x 0.1cm area noted to have slight bleeding when dressing was removed . right medial posterior thigh near gluteal fold 1cm x 1cm. area is a hard area that appears to be healing . *02/08/25 at 7:33 p.m. by DNP S, .date of service: 02/07/25 .wound initial .Resident #93 . The following wounds were evaluated during today's visit . Wound 1 Right Hip, Pressure Injury, Stage 3 . Wound 2 Right Thigh, Pressure Injury, Stage 3 . Wound 3 Left Thigh, Pressure Injury, Stage 3 . Patient is admitted with multiple wounds . Per report from DON . WOUND ASSESSMENT: .Wound: 1 . Status: Present on admission Location: Right Hip . Primary Etiology: Pressure Injury Severity: Stage 3 . Size: 6 cm x 1.5 cm x 0.1 cm. Actual area is 9 cm2. Actual volume is 0.9 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema Exudate: Light Serous .Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 2 . Status: Present on admission Location: Right Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 4 cm x 2 cm x 0.1 cm. Actual area is 8 cm2. Actual volume is 0.8 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 3 . Status: Present on admission Location: Left Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 1.5 cm x 1 cm x 0.1 cm. Actual area is 1.5 cm2. Actual volume is 0.15 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None .Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Recommendations consisting of: .We will re-evaluate this patient on our next visit (anticipated 1-2 weeks), Implement pressure relieving measures, offloading, and repositioning, as tolerated . Establish turning frequency based on the characteristics of the support surface and the patient's response . Protect skin from exposure to excessive moisture (periwound) with a barrier product. Use skin emollients to hydrate dry skin . Repositioning should be undertaken using the 30-degree tilted side-lying position (alternating right side, back, left side) . Plan of care discussed with facility staff .Wound# 1 Right Hip Pressure Injury Treatment Recommendations: .clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 2 Right Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 3 Left Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled . Record review of Resident #93's memorandum of transfer and physician certification dated 02/01/25 indicated emergency department diagnoses included pressure injury of contiguous region involving back, right buttock, and right hip, stage 2. Record review of Resident #93's hospital Discharge summary dated [DATE] did not reflect wound care orders. Record review of Resident #93's Braden scale for predicting pressure sore risk dated 02/01/25 indicated score of 16 which was at risk. Record review of Resident #93's weekly skin assessment dated [DATE] indicated .does the resident have a pressure, venous, arterial, diabetic, or surgical wound .yes .stage 2 PU, multiple shearing sites to right lateral thigh, right posterior thigh multiple, left posterior thigh, right buttocks, left posterior thigh . The facility's electronic medical record did not reflect a skin assessment on 02/08/25 or 02/09/25. Record review of Resident #93's wound assessment report dated 02/07/25 indicated .left thigh .Length: 1.50 cm .Width: 1.00 cm .Depth: 0.10 cm .left thigh .pressure injury .stage 3 .treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 4 cm .width: 2 cm .depth: 0.10 cm .right thigh .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 6 cm .width: 1.5 cm .depth: 0.10cm .right hip .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .specialty mattress will be implemented for residents with multiple stage 2 areas, stage 3, or stage 4 pressure injuries . During an observation and interview on 02/10/25 at 10:51 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or prop her heels with pillows. She said she could turn herself with the assist rails but staff did not place pillows behind her back, underneath her buttocks or between her legs. During an observation and interview on 02/10/25 at 3:05 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or propped her heels with pillows. During an observation on 02/11/25 at 10:02 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an observation and interview on 02/11/25 at 11:32 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff had not turn her every 2 hours or propped her heels with pillows. She said she had wounds on thighs, buttock, and hip. She said when she came from the hospital, there were dressings on two of the wounds. She said the facility did not do dressing changes every day. She said it depended on the staff as to what was done to her wounds. She said some staff did nothing and others would put cream on the wounds if they were closed. During an observation on 02/11/25 at 1:25 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an interview on 02/11/25 at 1:30 p.m., the ADCO said she was working the floor when Resident #93 was admitted . She said she was Resident #93's admitting nurse. She said if the admitting nurse was not a RN, then the nurse was only responsible for measuring and describing the wound. She said a RN, the DCO, or MD staged pressure wounds at the facility. She said upon admission the resident's MD should be notified and general wound care orders obtained. She said when the wound care doctor rounded on Fridays, the facility received specialized wound care orders. She said the wound care doctor came every Friday and the DCO notified him of who needed to be seen. She said after the wound care doctor rounded and made recommendations. She said the wound care doctor placed his recommendations in a progress note. She said the floor nurses or the DCO were responsible to place the recommendations in the facility's electronic medical record as an order. She said the DCO and ADCO were responsible for ensuring the wound care orders were followed through. She said the floor nurses were responsible for the resident's weekly skin assessments. She said the DON and DNP completed the weekly wound assessments when he rounded on Fridays. She said Resident #93 wounds on admission were shearing to her right hip, right buttocks, left thigh, and left buttocks. She said since she was not a RN, she did not stage Resident #93's wounds. She said Resident #93 arrived from the hospital with dressings over the wounds. She said she notified NP R by text or phone and let her know about Resident #93's shearing. She said she did not receive a response from NP R until shift change. She said she could not remember what NP R said about Resident #93's shearing. She said she knew she passed the message from NP R on to RN G when she gave report. She said she did not know what wound care treatment Resident #93 had been receiving since admission on [DATE]. She said she did not know the facility's policy or criteria on specialty mattress because she just started January 13, 2025. She said she did not know if Resident #93 met the facility's criteria for a specialty mattress but she probably did. She said other interventions for Resident #93's pressure wounds should have been frequent repositioning and incontinent care and a dietary consult. She said the dietician would be at the facility this week. She said since Resident #93 had a skin assessment on 02/01/25, then she should have had one on 02/08/25. She said even though the skin assessment was a day after the wound care doctor came, it should have been done by the floor nurse. She said skin assessments were important to ensure skin issues were not missed and proper wound care orders were in place. She said following doctors' orders were important to prevent the wound from declining and promote healing. She said the facility provided Resident #93 assist rails and trapeze bar to help with her mobility. On 02/11/25 at 2:23 p.m., called NP R and left voicemail. On 02/11/25 at 2:25 p.m., called RN G and left voicemail. During an interview on 02/11/25 at 2:58 p.m., NP R said she received a text message from LVN A that Resident #93 was admitted . She said she was currently driving and could not remember if the ADCO contacted her on admission about Resident #93's wounds. She said normally the facility followed the hospital's wound care orders and did not need them to give any orders. During an interview on 02/11/25 at 4:41 p.m., NP R called back and said LVN A and the ADCO called her on 02/01/25 about Resident #93. She said she told LVN A and the ADCO to resume all hospital orders and she would see Resident #93 on Tuesday, 02/04/25. During an interview on 02/11/25 at 6:01 p.m., RN G said she had worked at the facility for 6 years. She said she had taken care of Resident #93. She said she was texting with NP R on 02/05/05 about another resident lab work and NP R asked about Resident #93. She said NP R mentioned the hospital had not sent Resident #93 with wound care orders when she discharged . She said she told NP R that there were no wound care orders in Resident #93's hospital discharge paperwork. She said she told NP R, she did not know what the facility had been doing either for Resident #93's pressure wounds. She said NP R ordered collagen and a dry dressing and for the wound care doctor to see Resident #93. She said she did the ordered wound care on Resident #93 that night shift (02/05/25). She said she thought she placed the wound care orders NP R gave for Resident #93 in the facility's electronic medical records. She said Resident #93's wound care orders from NP R would be on her MAR if she did. She said it was important to have put in the wound care orders from NP R, so the next person knew what to do for Resident #93's wounds. She said not doing wound care treatments for Resident #93's wounds could cause further break down or increased stages. She said Resident #93's wounds would have been called stage 2's on admission. She said if the admission nurse was not a RN, then the next RN on duty was responsible for staging the pressure ulcer. She said if a wound needed to be staged by a RN, that information needed to be passed down by the next nurse or put on the 24-hour report. She said staging a pressure ulcer was important so the wound could be caught early and treated so it did not decline. She said she was not aware Resident #93's wounds were not staged until DNP S came on 02/07/25. She said a resident had to have pressure breakdown to be on a low air loss mattress. She said Resident #93 was on a bariatric pressure reduction mattress. She said she did not if they made bariatric specialty mattresses. She said if they made bariatric low air loss mattresses, Resident #93 would qualify for one because she had several areas of pressure breakdown. During an interview on 02/12/25 at 1:57 p.m., LVN D said nurses were responsible for resident's skin assessments. She said the skin assessments were due weekly and as needed. She said the weekly skin assessments should be charted in the resident medical records. She said a resident should be on a low air loss mattress if they have pressure ulcers or at the family request. She said heels should be floated for residents after hip surgery, residents who do not turn good, or residents with redness on their heels. She said residents should be repositioned every 2 hours. She said the RCP or LVN could do it but the RCP was primarily responsible. She said if a resident was able to turn themselves in the bed, the RCP should still encourage and help the resident turn every 2 hours. She said the RCP should be propping the resident with pillows to offload them when repositioning. She said the LVN should be ensuring the RCP are repositioning every 2 hours and offloading the residents by observation. She said a RN and LVN certified in wound care could stage pressure wounds. She said primarily RNs. She said if a resident needed a pressure wound staged, she would find a RN or contact the DCO. She said the facility had a telehealth option to stage wounds available now. She said the resident's doctor or the medical director was contacted for wound care orders. She said nursing management was responsible for taking the wound care doctor recommendations and making them orders. She said when the wound care doctor rounded on Fridays, he gave the DCO a copy of his recommendations on a piece of paper before he left. She said the wound care doctor left around 10 am. She said the bedside nurses were responsible for doing wound care treatments. She said the nurses documented on the MAR/TAR when wound care was completed. She said if wound care was not documented on the resident MAR/TAR, it could indicate it was not done. She said some residents did not show on the right screen to be done on the facility's computer system. She said skin assessments, wound care treatments, and repositioning/offloading were important to prevent skin breakdown and worsening of wound and not miss anything. During an interview on 02/12/25 at 5:25 p.m., RCP H said she had worked at the facility for 2 years. She said she found out a resident had wounds when she changed them. She said she was not really made aware by nursing staff or during report which resident had wounds. She said it depended on the severity of the wound what type of treatment the resident required. She said some resident needed cream and other had dressing changes by the nursing staff. She said RCPs were responsible for repositioning the residents every 2 hours with rounds. She said the residents should be alternated side to side and propped with pillows. She said residents stuck in the bed should have their heels offloaded. She said Resident #93 was stuck in the bed unless PT got her up. She said when she had Resident #93, she went in her room every once in a while, to remind her to turn but not every 2 hours. She said turning and offloading were important to prevent skin breakdown. She said constant pressure caused skin breakdown. During an interview on 02/12/25 at 5:49 p.m., the ADCO said wound care was documented on the resident's TAR in the facility's charting system. She said if wound care was not documented in the facility's charting system, it could indicate it was not done. She said the charge nurses were responsible for the resident's wound care. She said the DCO and ADCO should ensure the charge nurses were doing the ordered wound care treatments and documenting wound care on the resident's MAR/TARs. She said doing the resident's ordered wound care treatment was important to prevent decline of the wound, infection, prevent pain and more wounds. She said it was also important to do wound care to monitor the wound and follow doctor's orders. She said completion of the resident's skin assessment was documented on the TAR/MAR and a skin assessment form was also done. She said when she first started, she did not know that a skin assessment form had to be done even if the resident had no skin changes. She said she documented she completed Resident #15's skin assessment on the MAR/TAR but she did not do a new skin assessment form. She said she and the DCO Q were in the process, of putting a process in place to do chart audits to monitor skin assessments and wound care orders. During an interview on 02/12/25 at 6:57 p.m., DCO P, who was covering for DCO Q, said she expected nursing staff to follow physician orders. She said she expected nursing staff to document wound care on the MAR/TAR and/or progress note in the facility's charting system. She said if the wound care was not documented on the MAR/TAR and/or progress note, it could indicate it was not done. She said she expected nursing staff to order skin assessment on admission. She said she expected nursing staff to complete skin assessment weekly and with skin changes. She said the DCO ordered the resident's specialty mattresses and the charge nurse should ensure it was on the correct settings. She said all resident benefited from having their heels floated. She said but immobile residents especially needed their heels floated. She said she expected residents to be repositioned and offloaded at least every 2 hours by the RCPs. She said she preferred staging pressure wounds be done by the telehealth system. She said a RN or DCO should stage the resident pressure wounds. She said the ADCO and DCO should be ensuring nursing staff were doing wound care and skin assessments. She said all of these were important for wound prevention and management. During an interview on 02/12/25 at 7:34 p.m., the EDO said skin assessment were to be completed every 7 days in the facility's charting system. She said Resident #93 met the criteria for a low air loss mattress. She said the facility had a few specialty mattresses in house and she also could order one if needed. She said the DCO or the nursing staff who rounded with the wound care doctor was responsible for inputting his orders. She said it was important to document wound care and skin assessments to have an adequate clinical record. She said it was important to do wound care and skin assessments to promote wound healing. She said nursing management was responsible for ensuring nursing staff completed skin assessment and wound care. She said nursing management should be doing chart audits to ensure it was happening. Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .the purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment . Staging of wounds will be performed by a registered nurse or licensed nurse certified in wound care . Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours . A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up . Specialty mattresses will be implemented for residents with multiple stage II areas, stage Ill, or stage IV pressure injuries . Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less . Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days from day of completion . The EDO and DCE were notified of an IJ on 02/11/25 on 5:00 p.m., were given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 02/12/25 at 9:40 a.m. and included the following: [F635] Plan of Action: Resident #93 had wound care orders written on 02/11/25. A weekly wound assessment was completed on 02/11/25. A specialty mattress was placed on Resident #93's bed on 02/11/25. Resident #93's heels were floated effective 02/11/25. Skin sweep competed on 02/11/25 to ensure all skin issues were identified and had current orders and interventions in place. Completed 02/11/25 by Director of Clinical Education and designees. Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders. Completed 2/11/25 If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult. Completed 02/12/25. All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted . Education will also include the completion of weekly skin assessments per schedule. Completion 02/12/25 10:00 a.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift to begin 02/11/25. Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor. Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and procedures for wound care. All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee. Completed 2/12/2025 2:00 p.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers. Completed 2/12/2025 3:00 p.m. Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? Validation/Monitoring Tools? Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25. Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion. Beginning 02/12/25. Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely. Beginning 02/12/25. Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25. The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months. Beginning 02-12-25.? This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows: Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated wound care written on 02/11/25. Record review of Resident #93's skin assessment dated [DATE] completed by DCO P, indicated, .stage 3 pressure injuries x3 (right lateral hip, right thigh and left inner thigh) seen by AWC MD . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right thigh .2.2cmx3cmx0.2cm . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .left inner thigh .1cmx0.1cmx0.2cm . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right lateral hip .4.5cmx1.3cmx0.2cm . Record review of the facility's Residents with Pressure Injuries provided by the EDO on 02/11/25 indicated seven residents with pressure injuries. Five residents were included in finalized sample. Resident #11 and Resident #15 had missing documentation of wound care and skin assessments. Record review of the facility's weekly skin assessment dat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 3 of 7 residents reviewed for quality of care. (Resident #93, Resident #11, and Resident #15) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to perform a weekly skin assessment on Resident #93 that was due on 02/08/25. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. The facility failed to implement a specialty mattress (use in the treatment and prevention of pressure ulcers) for Resident #93, per their policy, due to multiple stage 3 pressure injuries on 02/01/25. The facility failed to float Resident #93's heels on 02/10/25 and 02/11/25. The facility failed to offload and/or reposition Resident #93 every 2 hours on 02/10/25 and 02/11/25. An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 02/12/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on the process of carrying out orders for residents admitted with wounds or obtaining orders if no orders accompanied the resident, completion of weekly skin assessments, wound care orders, skin management policy, and pressure ulcer prevention and interventions for residents with pressure ulcers. 2.The facility failed to document wound care was performed on Resident #11, on 02/01/25, 02/02/25, 02/03/25, 02/05/25, and 02/10/25. The facility failed to document Resident #11's weekly skin assessments on 01/02/25, 01/15/25, 01/22/25, 01/29/25, and 02/04/25. 3.The facility failed to document wound care was performed on Resident #15's right upper thigh wound on 01/17/25, 01/20/25, and 01/29/25. The facility failed to document Resident #15's weekly skin assessments on 01/19/25, 01/26/25, 02/02/25, and 02/09/25. Theses failures could place residents at risk for wound deteriorations and more wound development. Findings included: 1. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), morbid obesity (is a medical condition characterized by excessive body weight that significantly impacts health and well-being), and pressure ulcer of right hip, left hip, and other sites, stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed). Record review of the MDS, on 02/10/25, indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit. Record review of Resident #93's care plan dated 02/03/25 indicated: *Resident #93 was admitted with stage 3 pressure ulcer to right thigh. Interventions included assess and document skin condition every week, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with Stage 3 pressure ulcer to right hip. Interventions included assess and document skin condition every week, monitor nutritional intake, weight, lab values and report significant changes to MD, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with stage 3 pressure ulcer to left thigh. Intervention included administer treatments as ordered and monitor for effectiveness, monitor nutritional status, and obtain and monitor lab/diagnostic work as ordered. Record review of Resident #93's consolidated physician orders dated active as of 02/11/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. The consolidated physician order did not reflect wound care orders for Resident #93's left thigh, right hip, and right thigh pressure ulcer on admission [DATE]). Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/02/25. Discontinued 02/09/25. No documentation was noted on 02/02/25 and 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. Record review of Resident #93's progress note dated 01/12/25-02/12/25 indicated: *02/01/25 at 7:47 p.m. by the ADCO, .new admission skin assessment .the following areas were all noted upon admission to the facility . Right Lateral thigh shearing 2cm x 5cm x0.1cm open area without exudate with surrounding scaring . Right gluteal area shearing 0.4cm x 0.4cm x 0.1 cm no exudate noted . Right lateral hip shearing with surrounding scaring 5.5cm x 1.4cm x 0.1cm no exudate noted . Right Posterior hip shearing 1.3cm x 0.9cm x 0.1cm no exudate noted . Right posterior thigh near gluteal fold 1.2cm x 0.1cm. Area is a hard area that appears to be healing . Left posterior thigh shearing 1.2cm x 1cm x 0.1cm area noted to have slight bleeding when dressing was removed . right medial posterior thigh near gluteal fold 1cm x 1cm. area is a hard area that appears to be healing . *02/08/25 at 7:33 p.m. by DNP S, .date of service: 02/07/25 .wound initial .Resident #93 . The following wounds were evaluated during today's visit . Wound 1 Right Hip, Pressure Injury, Stage 3 . Wound 2 Right Thigh, Pressure Injury, Stage 3 . Wound 3 Left Thigh, Pressure Injury, Stage 3 . Patient is admitted with multiple wounds . Per report from DON . WOUND ASSESSMENT: .Wound: 1 . Status: Present on admission Location: Right Hip . Primary Etiology: Pressure Injury Severity: Stage 3 . Size: 6 cm x 1.5 cm x 0.1 cm. Actual area is 9 cm2. Actual volume is 0.9 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema Exudate: Light Serous .Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 2 . Status: Present on admission Location: Right Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 4 cm x 2 cm x 0.1 cm. Actual area is 8 cm2. Actual volume is 0.8 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 3 . Status: Present on admission Location: Left Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 1.5 cm x 1 cm x 0.1 cm. Actual area is 1.5 cm2. Actual volume is 0.15 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None .Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Recommendations consisting of: .We will re-evaluate this patient on our next visit (anticipated 1-2 weeks), Implement pressure relieving measures, offloading, and repositioning, as tolerated . Establish turning frequency based on the characteristics of the support surface and the patient's response . Protect skin from exposure to excessive moisture (periwound) with a barrier product. Use skin emollients to hydrate dry skin . Repositioning should be undertaken using the 30-degree tilted side-lying position (alternating right side, back, left side) . Plan of care discussed with facility staff .Wound# 1 Right Hip Pressure Injury Treatment Recommendations: .clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 2 Right Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 3 Left Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled . Record review of Resident #93's memorandum of transfer and physician certification dated 02/01/25 indicated emergency department diagnoses included pressure injury of contiguous region involving back, right buttock, and right hip, stage 2. Record review of Resident #93's hospital Discharge summary dated [DATE] did not reflect wound care orders. Record review of Resident #93's Braden scale for predicting pressure sore risk dated 02/01/25 indicated score of 16 which was at risk. Record review of Resident #93's weekly skin assessment dated [DATE] indicated .does the resident have a pressure, venous, arterial, diabetic, or surgical wound .yes .stage 2 PU, multiple shearing sites to right lateral thigh, right posterior thigh multiple, left posterior thigh, right buttocks, left posterior thigh . The facility's electronic medical record did not reflect a skin assessment on 02/08/25 or 02/09/25. Record review of Resident #93's wound assessment report dated 02/07/25 indicated .left thigh .Length: 1.50 cm .Width: 1.00 cm .Depth: 0.10 cm .left thigh .pressure injury .stage 3 .treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 4 cm .width: 2 cm .depth: 0.10 cm .right thigh .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 6 cm .width: 1.5 cm .depth: 0.10cm .right hip .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .specialty mattress will be implemented for residents with multiple stage 2 areas, stage 3, or stage 4 pressure injuries . During an observation and interview on 02/10/25 at 10:51 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or prop her heels with pillows. She said she could turn herself with the assist rails but staff did not place pillows behind her back, underneath her buttocks or between her legs. During an observation and interview on 02/10/25 at 3:05 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or propped her heels with pillows. During an observation on 02/11/25 at 10:02 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an observation and interview on 02/11/25 at 11:32 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff had not turn her every 2 hours or propped her heels with pillows. She said she had wounds on thighs, buttock, and hip. She said when she came from the hospital, there were dressings on two of the wounds. She said the facility did not do dressing changes every day. She said it depended on the staff as to what was done to her wounds. She said some staff did nothing and others would put cream on the wounds if they were closed. During an observation on 02/11/25 at 1:25 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an interview on 02/11/25 at 1:30 p.m., the ADCO said she was working the floor when Resident #93 was admitted . She said she was Resident #93's admitting nurse. She said if the admitting nurse was not a RN, then the nurse was only responsible for measuring and describing the wound. She said a RN, the DCO, or MD staged pressure wounds at the facility. She said upon admission the resident's MD should be notified and general wound care orders obtained. She said when the wound care doctor rounded on Fridays, the facility received specialized wound care orders. She said the wound care doctor came every Friday and the DCO notified him of who needed to be seen. She said after the wound care doctor rounded and made recommendations. She said the wound care doctor placed his recommendations in a progress note. She said the floor nurses or the DCO were responsible to place the recommendations in the facility's electronic medical record as an order. She said the DCO and ADCO were responsible for ensuring the wound care orders were followed through. She said the floor nurses were responsible for the resident's weekly skin assessments. She said the DON and DNP completed the weekly wound assessments when he rounded on Fridays. She said Resident #93 wounds on admission were shearing to her right hip, right buttocks, left thigh, and left buttocks. She said since she was not a RN, she did not stage Resident #93's wounds. She said Resident #93 arrived from the hospital with dressings over the wounds. She said she notified NP R by text or phone and let her know about Resident #93's shearing. She said she did not receive a response from NP R until shift change. She said she could not remember what NP R said about Resident #93's shearing. She said she knew she passed the message from NP R on to RN G when she gave report. She said she did not know what wound care treatment Resident #93 had been receiving since admission on [DATE]. She said she did not know the facility's policy or criteria on specialty mattress because she just started January 13, 2025. She said she did not know if Resident #93 met the facility's criteria for a specialty mattress but she probably did. She said other interventions for Resident #93's pressure wounds should have been frequent repositioning and incontinent care and a dietary consult. She said the dietician would be at the facility this week. She said since Resident #93 had a skin assessment on 02/01/25, then she should have had one on 02/08/25. She said even though the skin assessment was a day after the wound care doctor came, it should have been done by the floor nurse. She said skin assessments were important to ensure skin issues were not missed and proper wound care orders were in place. She said following doctors' orders were important to prevent the wound from declining and promote healing. She said the facility provided Resident #93 assist rails and trapeze bar to help with her mobility. On 02/11/25 at 2:23 p.m., called NP R and left voicemail. On 02/11/25 at 2:25 p.m., called RN G and left voicemail. During an interview on 02/11/25 at 2:58 p.m., NP R said she received a text message from LVN A that Resident #93 was admitted . She said she was currently driving and could not remember if the ADCO contacted her on admission about Resident #93's wounds. She said normally the facility followed the hospital's wound care orders and did not need them to give any orders. During an interview on 02/11/25 at 4:41 p.m., NP R called back and said LVN A and the ADCO called her on 02/01/25 about Resident #93. She said she told LVN A and the ADCO to resume all hospital orders and she would see Resident #93 on Tuesday, 02/04/25. During an interview on 02/11/25 at 6:01 p.m., RN G said she had worked at the facility for 6 years. She said she had taken care of Resident #93. She said she was texting with NP R on 02/05/05 about another resident lab work and NP R asked about Resident #93. She said NP R mentioned the hospital had not sent Resident #93 with wound care orders when she discharged . She said she told NP R that there were no wound care orders in Resident #93's hospital discharge paperwork. She said she told NP R, she did not know what the facility had been doing either for Resident #93's pressure wounds. She said NP R ordered collagen and a dry dressing and for the wound care doctor to see Resident #93. She said she did the ordered wound care on Resident #93 that night shift (02/05/25). She said she thought she placed the wound care orders NP R gave for Resident #93 in the facility's electronic medical records. She said Resident #93's wound care orders from NP R would be on her MAR if she did. She said it was important to have put in the wound care orders from NP R, so the next person knew what to do for Resident #93's wounds. She said not doing wound care treatments for Resident #93's wounds could cause further break down or increased stages. She said Resident #93's wounds would have been called stage 2's on admission. She said if the admission nurse was not a RN, then the next RN on duty was responsible for staging the pressure ulcer. She said if a wound needed to be staged by a RN, that information needed to be passed down by the next nurse or put on the 24-hour report. She said staging a pressure ulcer was important so the wound could be caught early and treated so it did not decline. She said she was not aware Resident #93's wounds were not staged until DNP S came on 02/07/25. She said a resident had to have pressure breakdown to be on a low air loss mattress. She said Resident #93 was on a bariatric pressure reduction mattress. She said she did not if they made bariatric specialty mattresses. She said if they made bariatric low air loss mattresses, Resident #93 would qualify for one because she had several areas of pressure breakdown. During an interview on 02/12/25 at 1:57 p.m., LVN D said nurses were responsible for resident's skin assessments. She said the skin assessments were due weekly and as needed. She said the weekly skin assessments should be charted in the resident medical records. She said a resident should be on a low air loss mattress if they have pressure ulcers or at the family request. She said heels should be floated for residents after hip surgery, residents who do not turn good, or residents with redness on their heels. She said residents should be repositioned every 2 hours. She said the RCP or LVN could do it but the RCP was primarily responsible. She said if a resident was able to turn themselves in the bed, the RCP should still encourage and help the resident turn every 2 hours. She said the RCP should be propping the resident with pillows to offload them when repositioning. She said the LVN should be ensuring the RCP are repositioning every 2 hours and offloading the residents by observation. She said a RN and LVN certified in wound care could stage pressure wounds. She said primarily RNs. She said if a resident needed a pressure wound staged, she would find a RN or contact the DCO. She said the facility had a telehealth option to stage wounds available now. She said the resident's doctor or the medical director was contacted for wound care orders. She said nursing management was responsible for taking the wound care doctor recommendations and making them orders. She said when the wound care doctor rounded on Fridays, he gave the DCO a copy of his recommendations on a piece of paper before he left. She said the wound care doctor left around 10 am. She said the bedside nurses were responsible for doing wound care treatments. She said the nurses documented on the MAR/TAR when wound care was completed. She said if wound care was not documented on the resident MAR/TAR, it could indicate it was not done. She said some residents did not show on the right screen to be done on the facility's computer system. She said skin assessments, wound care treatments, and repositioning/offloading were important to prevent skin breakdown and worsening of wound and not miss anything. During an interview on 02/12/25 at 5:25 p.m., RCP H said she had worked at the facility for 2 years. She said she found out a resident had wounds when she changed them. She said she was not really made aware by nursing staff or during report which resident had wounds. She said it depended on the severity of the wound what type of treatment the resident required. She said some resident needed cream and other had dressing changes by the nursing staff. She said RCPs were responsible for repositioning the residents every 2 hours with rounds. She said the residents should be alternated side to side and propped with pillows. She said residents stuck in the bed should have their heels offloaded. She said Resident #93 was stuck in the bed unless PT got her up. She said when she had Resident #93, she went in her room every once in a while, to remind her to turn but not every 2 hours. She said turning and offloading were important to prevent skin breakdown. She said constant pressure caused skin breakdown. During an interview on 02/12/25 at 5:49 p.m., the ADCO said wound care was documented on the resident's TAR in the facility's charting system. She said if wound care was not documented in the facility's charting system, it could indicate it was not done. She said the charge nurses were responsible for the resident's wound care. She said the DCO and ADCO should ensure the charge nurses were doing the ordered wound care treatments and documenting wound care on the resident's MAR/TARs. She said doing the resident's ordered wound care treatment was important to prevent decline of the wound, infection, prevent pain and more wounds. She said it was also important to do wound care to monitor the wound and follow doctor's orders. She said completion of the resident's skin assessment was documented on the TAR/MAR and a skin assessment form was also done. She said when she first started, she did not know that a skin assessment form had to be done even if the resident had no skin changes. She said she documented she completed Resident #15's skin assessment on the MAR/TAR but she did not do a new skin assessment form. She said she and the DCO Q were in the process, of putting a process in place to do chart audits to monitor skin assessments and wound care orders. During an interview on 02/12/25 at 6:57 p.m., DCO P, who was covering for DCO Q, said she expected nursing staff to follow physician orders. She said she expected nursing staff to document wound care on the MAR/TAR and/or progress note in the facility's charting system. She said if the wound care was not documented on the MAR/TAR and/or progress note, it could indicate it was not done. She said she expected nursing staff to order skin assessment on admission. She said she expected nursing staff to complete skin assessment weekly and with skin changes. She said the DCO ordered the resident's specialty mattresses and the charge nurse should ensure it was on the correct settings. She said all resident benefited from having their heels floated. She said but immobile residents especially needed their heels floated. She said she expected residents to be repositioned and offloaded at least every 2 hours by the RCPs. She said she preferred staging pressure wounds be done by the telehealth system. She said a RN or DCO should stage the resident pressure wounds. She said the ADCO and DCO should be ensuring nursing staff were doing wound care and skin assessments. She said all of these were important for wound prevention and management. During an interview on 02/12/25 at 7:34 p.m., the EDO said skin assessment were to be completed every 7 days in the facility's charting system. She said Resident #93 met the criteria for a low air loss mattress. She said the facility had a few specialty mattresses in house and she also could order one if needed. She said the DCO or the nursing staff who rounded with the wound care doctor was responsible for inputting his orders. She said it was important to document wound care and skin assessments to have an adequate clinical record. She said it was important to do wound care and skin assessments to promote wound healing. She said nursing management was responsible for ensuring nursing staff completed skin assessment and wound care. She said nursing management should be doing chart audits to ensure it was happening. Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .the purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment . Staging of wounds will be performed by a registered nurse or licensed nurse certified in wound care . Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours . A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up . Specialty mattresses will be implemented for residents with multiple stage II areas, stage Ill, or stage IV pressure injuries . Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less . Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days from day of completion . The EDO and DCE were notified of an IJ on 02/11/25 on 5:00 p.m., were given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 02/12/25 at 9:40 a.m. and included the following: F686- Skin Integrity/Pressure Ulcer Plan of Action: Resident #93 had wound care orders written on 02/11/25. A weekly wound assessment was completed on 02/11/25. A specialty mattress was placed on Resident #93's bed on 02/11/25. Resident #93's heels were floated effective 02/11/25. Skin sweep competed on 02/11/25 to ensure all skin issues were identified and had current orders and interventions in place. Completed 02/11/25 by Director of Clinical Education and designees. Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders. Completed 2/11/25 If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult. Completed 02/12/25. All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted . Education will also include the completion of weekly skin assessments per schedule. Completion 02/12/25 10:00 a.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift to begin 02/11/25. Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor. Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and procedures for wound care. All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee. Completed 2/12/2025 2:00 p.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers. Completed 2/12/2025 3:00 p.m. Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? Validation/Monitoring Tools? Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25. Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion. Beginning 02/12/25. Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely. Beginning 02/12/25. Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25.?? The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months. Beginning 02-12-25.? This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows: Rec[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult the physician when a resident had a significant change in physical and mental condition for 1 of 7 residents reviewed for physician notification (Resident #1.) LVN A noted Resident #1 had a change in condition on 02/09/24 around 2:00 p.m. but LVN A did not consult the physician until 8:00 p.m. Facility staff failed to consult the physician when Resident #1's oxygen level was 87 percent and had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. The resident was intubated and placed in ICU. An Immediate Jeopardy (IJ) was identified on 03/12/24. The IJ template was provided to the facility on [DATE] at 1:05 p.m. While the IJ was removed on 03/13/24, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of not having their physician consulted when changes occur that may require treatment alterations and could lead to additional pain and suffering. Findings included: Record of Resident #1's face sheet dated 3/5/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were congestive heart failure, bipolar disorder, schizoaffective disorder (mental health disorder including symptoms such as hallucinations, delusions, disorganized thinking, mania, and depression) , dementia, and lack of coordination. Record review of Resident #1's admission MDS dated [DATE] indicated moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident required partial to moderate assistance with hygiene showers, upper body dressing, lower body dressing. The resident required partial to moderate assistance with transferring from chair to bed and toilet. Record review of Resident #1's care plan dated 1/5/24 indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were: Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia (side effect of antipsychotic medications that cause involutary movements of the head and body including lip smacking, grimacing, eye blinking, and repetitive movements), seizures, and cardiac changes. Record review of Resident #1's nursing note indicated: On 2/8/24 at 1:41 p.m. resident continued to be very sleepy, did not wake up to take meds and ate 30 percent of lunch. She was in the wheelchair in the hallway sleeping. Her vital signs were stable. On 2/9/24 at 5:09 a.m. the resident was in bed with eyes closed easily arouse with respirations even and unlabored. No shortness of breath noted discontinued Venlafaxine HCL day three no adverse reactions. No signs and symptoms of sedations. The residence behavior within normal limits. No pain or discomfort observed. At 8:50 a.m. the resident blood pressure medications metoprolol and lisinopril were held due to blood pressure of 93/51. At 8:34 p.m. medications were held due to residence status. At 8:50 p.m. the resident was sent to the hospital due to change in condition. (There were no other notes or assessments.) Signed by LVN A Record review of Resident #1's EMS report dated 2/9/24 indicated arrived at the scene at 8:33 p.m. Upon arrival at the scene the patient was lying in bed, mumbling, and reaching aimlessly into the air. The patient could tell us her name and the staff ( LVN A) stated she was a [AGE] year-old female, and she started acting strangely at approximately 2:00 p.m. The patient was placed on monitor and vitals were obtained her temperature was 100.6 Fahrenheit. blood pressure was 92/61, respirations were 18 and labored and her oxygen stat was 93 percent. The sounds in her lungs revealed bubbling and gurgling. She was given a nebulizer treatment which improved her lung sounds and was placed on 15 mL of oxygen via facemask. The patient was transported to the ER and arrived at the destination at 9:15 p.m. The chief complaint was, altered consciousness, and lethargy (unusual decreased consciousness) for at least six hours and fever. Record review of Resident #1's emergency hospital records dated 2/9/24 with the arrival time of 9:20 p.m. indicated the patient was found in respiratory distress, low blood pressure and rapid heartbeat. On arrival the patient was in respiratory distress on a non-breather mask at 15 L oxygen. The nurses at the nursing home stated there was a possible aspiration (when food, liquid, vomit, or foreign object enters the lungs) episode today. Her blood pressure was 124/68, her pulse was 142, her temp was 103, her oxygen stat was 94%. The diagnosis was sepsis (the body's response to an infection or widespread inflammation) secondary to pneumonia. The patient will be transferred to an ICU for further management due to the complexity of the case and being a full code. Patient received from a nursing home with respiratory distress with a stat of 87 per nursing home. Staff said the condition noted at 2:00 p.m. The patient vomited around that time. She was transferred to the hospital on 2/10/24 at 2:00 a.m. Record review of Resident #1's hospital records indicated the resident was admitted to their facility on 2/10/24 on arrival she was on 12 L nasal cannula and unresponsive with blood pressures in the 80 systolic and O2 stats in the 80s. She was emergently intubated (to establish an airway and prevent secondary brain injury). During an interview on 3/5/24 at 3:36 p.m. the DON said she received a message from LVN A on the night of 2/9/24. She said LVN A sent Resident #1 to the ER because she was not acting herself. The DON said LVN A said she contacted NP F and she said to send Resident #1 out. The DON said LVN A said Resident #1 did not eat supper and looked like she vomited something black. The LVN said Resident# 1's O2 stat was at 87 percent. The DON said the facility Interact transfer form was not in the clinical record and there was nothing in the nursing notes about Resident #1's condition prior to hospitalization. The DON said from what she saw in Resident #1's clinical record LVN A did not make the clinical document, she had likely assessed Resident #1 because she told her the blood pressure and oxygen status, but she did not document anything. During an interview on 3/5/24 at 5:05 p.m. RN C said Resident #1 had a steady decline. She said Resident #1 would repeat things over and over and over and sit in the hallway and yell out. She said the doctor put Resident #1 on Venlafaxine to aide with her behaviors. RN C said Resident#1 had been a lethargic for several days, the medications were reduced and discontinued. She said on 2/9/24 Resident #1 was sitting at the assisted dining table and refused to eat. The RN said Resident #1 appeared to be lethargic. She said Resident #1 would not wake up, and just blink, that was all. The RN said she was the one who tried to assist Resident #1 to eat and when she tried to put something in her mouth, she would not respond. She said the Resident #1 did not appear to be with it enough to chew. The RN said she was afraid Resident #1 would choke so she refused to feed her. She said she was not her nurse but had observed the resident was not her usual self for several days, and she was just assisting in the dining room. RN C said she thought Resident #1 was just having symptoms from the medications. During an interview on 3/5/24 at 5:07 p.m. LVN G said Resident #1 had been sleepy for the last couple of days. She said she worked with the Resident #1 the day before she was hospitalized on [DATE] and the Resident seemed fine. She said Resident #1's vitals were within normal limits for Resident #1 . She said Resident #1 was not coughing or wheezing and had no rattle. The LVN G said Resident #1's voice was raspy as always but not wet. She said the Resident #1 was put on some new medications because she would sit in the hallway and yell and scream. The LVN said when most residents that are put on the medications, they are usually sleepy the first few days. She said there were some changes with the Venlafaxine and it was discontinued. She said she administered the medication as prescribed. She said Resident#1 would wake up and respond when spoken to. During an interview on 3/5/24 at 5:11 p.m. CNA B said she worked at the facility for about 1 year. She said when Resident #1 first arrived at the facility she would repeat things over and over. She said Resident #1 had a moderate decline. She said she was at the facility on 2/9/24 when Resident #1 was sent to the hospital. She said when she arrived that day at 2:00 p.m. Resident #1 could hardly do anything. She said Resident #1 was just sitting in the wheelchair with her head back and appeared to be asleep but was hard to awaken. She said it was like Resident #1 could not hold her head down at all. CNA B said Resident #1 had been kind of out of it ( real sleepy and not herself, but she would respond) for the last couple of days, however on that day she would barley respond. She said all the nurses were aware the resident had a decline; Resident #1 would usually be placed right in front of the nurses' station. CNA B said the nurses said Resident #1 was like that because some medication they had put her on made her sleepy. CNA B said Resident #1 would not eat supper on 2/9/24, she would not open her mouth or hold her head down to take a bite. She had informed LVN A Resident #1 could not eat. She said that night around 8:00 p.m. when she was putting Resident #1 to bed, she had some black stuff coming out of her mouth and she told the nurse. CNA B said it was at that time the LVN A came and looked at Resident #1 and sent her out to the hospital. During an interview on 3/11/24 at 11:20 a.m. the DON said she saw LVN A but did not talk to her about Resident #1. She said she thought the LVN could not complete a note or an assessment after the Resident #1 was deceased . The DON said it appeared LVN A came in at 2p on 2/9/24 and failed to assess the resident when a change in condition was noted or to document what was going on with Resident#1. During a telephone interview on 3/11/24 at 11:25 a.m. LVN A said when she came to work on 2/9/24 at 2:00 p.m. Resident # 1 was in her wheelchair asleep and had her neck/head back. She said Resident #1 was usually up talking but she was not her normal self. She said when they went to supper the resident did not eat anything. She said around 8:00 p.m. she texted NP F and she told her Resident #1 need to be sent out. She said she texted the physician at the same time around 8:00 p.m. The LVN said she checked her vital signs and everything. She said she did not remember if she had written anything down or not. She said she worked PRN and did not know what was going on with Resident #1. She said she assessed her but did not complete the assessment because she did not have time. She said after they laid Resident#1 down that night her breathing was shallow, her 02 stat was under 90. She said Resident #1 was laying in the bed reaching in the air. The LVN said Resident #1 did not have a fever and EMS did not say anything about her breathing. During an interview on 3/11/24 at 11:44 a.m. NP F said she felt the nurses were good about reporting things, and she received mixed messages about Resident #1. She said one nurse would report one thing and one nurse would see something different. She said she had reports that Resident #1 would eat good one day and one day not. She said the reports that she received about Resident #1 were not consistent. She said she was shocked when they reported the resident had died, it was totally unexpected. On 2/9/24 at 8:04 p.m. she received a text from LVN A. She said the text stated Resident #1 was not acting herself, 02 stat was 87 at the time, bp was 117/78, and heart rate 67. NP F said Resident #1 was started on a high dose of Venlafaxine because she appeared to be able to tolerate high doses of medications. She said everyone was different, they held it ,decreased it, watched it, and discontinued the medication. She said she was not aware if anyone called her to restart the medications or when she told the staff to start Resident #1 back on the Venlafaxine. However, from the calls she had received the resident did not tolerate the medications well and she had discontinued it on 2/7/24 due to reports of continued lethargic behaviors. She said she did want Resident #1 to be monitored for low blood pressure and fever for drug interactions with the Venlafaxine and Resident #1's current medication for possible serotonin overdose. She said the Serotonin Syndrome had several different symptoms and could cause a resident medical distress. She said that was why she wanted the resident checked for fever and low blood pressure. She did not know that those checks did not appear to be done. She said she had gotten some calls from LVN G and RN D about Resident #1 but no acute calls. During an interview on 3/11/24 at 12:00 p.m. RN D said she had worked with Resident #1 the day before she had gone to the hospital. She said Resident #1 was sleepy but would respond. She said other than being sleepy she was her normal self. She said the resident did not have a cough and had taken her medications without incident. She had eaten only part of her lunch that day, but she did not note any distress. During an interview on 3/11/24 at 12:05 p.m. CNA H said when she arrived at the facility on 2/8/24 at 6:00 a.m. She said Resident #1 was extremely hard to get up that morning. She said Resident #1 seemed overly tired. She said Resident #1 was less coherent. CNA H said normally Resident #1 wanted to go out to smoke or go to the dining room to wait on breakfast but said did not want to do any of those things. She said for the last few days Resident #1 would sleep quite a bit. She said most days she would sleep some because she may have been up the night before. She said on that day she was sleeping and not eating. CNA H said RN D was the nurse on 2/8/24 and she knew Resident #1 was more tired than usual because she had told her. She had also placed the resident close to the nurse's station. During an interview and record review on 3/11/24 at 3:40 p.m. the DON said review of the EMS and hospital records indicated LVN A had told the hospital Resident #1 had a change in condition around 2:00 p.m. The DON said she was not made aware of the change until around 8:00 p.m. She could not say why the nurse had waited 6 hours before assessing Resident #1 and sending her out to the hospital. During a telephone interview on 3/11/24 at 3:50 p.m. LVN A said she told the hospital the Resident #1 had thrown up at about 2:00 p.m. and it was black. They had chocolate cake, she did not know if it was the cake or not. She also told the hospital Resident #1 had a change in condition around 2p. During an interview on 3/12/24 at 9:41 a.m. the NP F said there were no reports of any changes with Resident #1 until around 8:00 p.m. on 2/9/24. During an interview on 3/12/24 at 10:01 the BOM said that the a family member texted her the day Resident #1 went to the hospital to say she seemed over medicated they could not get her to wake up. She said she had told the nurse. The family member had texted her again, but she did not recall exactly what the text said. During a telephone interview on 3/12/24 at 10:30 a.m. a family member said on the day Resident #1 went to the hospital her family member called her crying and upset because Resident #1 could not seem to get her breath to talk. That Family member said they were there on 2/9/24 about 2 or 3 in the afternoon. The family member said whoever she talked to told her Resident #1 had been like that for two or three days. The family member said Resident #1 was sitting in the wheelchair with her head back and she could not get her to really wake up. The family member said Resident#1 had a bruise on her face that looked like it was a few days old. The aide told her the resident had fallen in her room a few days earlier. The family member said they wheeled Resident #1 out by the nurse's station because they were concerned, she was not doing well. The family member said they talked to the nurse behind the nurse's station and asked what was going on with Resident#1? The family member said she did not really get an answer and was upset and confused when she left the facility. She thought something was wrong, but the staff acted like Resident #1 was fine, but she was not. The family member said the Resident had black stuff coming out of her mouth. She said they could not get her head down so she could clean her mouth, it looked like she had food in her mouth. They said Resident #1's neck was in almost an awkward position held back and she did not appear to be able to lift her head. The family member said when Resident #1 arrived at the hospital food was stuck to the top of her mouth, and it was so bad they had to throw the dentures away. The food looked like it had been there for a long time. The family member said the Resident #1's neck was held in a back position when she was in the hospital even while lying in the bed. It was like her neck was paralyzed in that position. During an interview on 3/13/24 at 1:21 p.m. CNA K said Resident #1 was not herself at all. She said some nurses they reported to would act and others would not. She said Resident #1 had a tremendous change. She was loud and very vocal. They changed her medications, and she was zonked out, sleeping like she was not in the world. She said they reported their concerns to the nurses, and they would say it was just the medication. CNA K said the last 3- or 4-days Resident #1 was in the facility, it did not matter if Resident #1 was up in the chair or in bed her head was back, her mouth was open, and she was asleep. During an interview on 3/13/24 at 1:45 p.m. RN D said she was thinking Resident #1's problem was the change in medications. She had seen her in the hallway picking things out of the air and she was still asleep. She said she had not really assessed her but if someone told her black stuff was coming out of her mouth, she would have assessed her for sure. During an interview on 3/13/24 at 4:26 p.m. RN C said she was not Resident #1's nurse on 2/9/24. She said at dinner she tried to feed Resident #1, and she could not eat. The RN said she refused to feed Resident #1 and told the aide not to even try. She said it appeared Resident #1 was unable to hold her head down to eat. She sat with her head back like she was asleep and was not responding appropriately at all. She said LVN A was in the dining room and heard the interactions about Resident #1 not being able to eat dinner. RN C said after the Resident #1 had gone to the hospital and LVN A asked if she had feed the resident anything. She said LVN A said something was coming out of Resident #1'smouth. RN C said Resident #1 had a change in condition, she was sleeping and could not be awaken, her head was back, and she could not eat. She said she asked the DON today what she should have done? She said Resident #1 was not her resident, and she noted a change in condition. LVN C said the DON told her if the other nurse did not assess the resident, then she needed to assess, make all the necessary calls and documentation. Record review of the facilities change in a resident condition or status policy, last revised May 2017, indicated our facility shall promptly notify the resident attending physician changes in the resident medical condition. The nurse will notify the resident attending physician on call when there has been a significant change in the resident, physical, emotional, or mental condition. A significant change of condition is a major decline or improvement, in the resident status that will not normally resolve itself without intervention impacts more than one and impacts more than one area of the resident health. Prior to notifying the physician or healthcare provider the nurse will make detail observations and gather relevant pertinent information for the provider, including for example, information provided by the in-communication form, the nurse will record in the resident record information relative to changes in the resident medical mental condition or status. The Administrator was notified on 03/12/24 at 1:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 03/12/24 at 1:05 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 03/13/24 at 11:12 a.m. and included: [Plan of Removal F-580 Action: The Director of Infection Prevention will provide education on company's policy related to physician and/or family notification of resident changes to the DCO. 3/12/2024. In-service on company's policy related to assessment of a resident when they experience a change of condition to all nurses conducted by the DCO/Designee. A copy of the inservice regarding change of condition will be provided for review. The policy and procedure outlines examples of occurrences that would necessitate notification of a change of condition. If an aide reports a change in condition, the nurse is expected to evaluate the resident and make a determination of necessary additional treatment. Nurse aides were re-educated on utilization of the Stop and Watch notification in Point Click Care for changes in condition on 3/13/24. Nurses were educated on reviewing the PCC dashboard for the automatically triggered alerts with visual demonstration on 3/13/24. The facility assessment form will be completed when residents are sent to the hospital. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by 3/13/2024. This education will also be included in all new nurse orientation for any newly hired nurses. DCO/Designee to complete chart reviews daily during the clinical meeting to ensure physician and/or family notification for new orders and/or change in conditions are happening per policy. 3/13/2024 - A random audit was conducted on 3/12/24 and no additional residents were identified as affected. The Medical Director has been notified of the immediate jeopardy and reviewed current policy and procedures for notification of new orders and/or change in condition. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with the notification of physician and family policy and procedures. 3/12/2024 ] On 03/13/24 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the staff disciplinary actions indicated they were completed. Review of the Chart audits on medications indicated they were completed and all residents on blood pressure medications had parameters in place. Review of the medication competencies on medication pass were completed for the staff that were present. Review of disciplinary action for LVN A dated 3/13/24 indicated the employee had failed to notify the physician and provide an assessment for a resident prior to hospitalization. The employee will follow facility policy regarding physician notification and assessing a resident when they have a changing condition. The first employee will timely and accurately document all the Above in the computer system. Any future violations of this policy will result in termination. The form indicated spoke to the employee on the phone and she will be signed up upon return to work. Interviews were conducted with facility staff on 3/13/14 between 12:59 p.m. and 4:59 p.m. At 12:29 p.m. CNA I worked 6a to 2p At 1:07 p.m. CNA J worked 6a to 2p At 1:21p.m. CNA K worked 6a to 2p and 10 p to 6a At 1:45 p.m. RN D worked 6a to 2p At 2:16 p.m. LVN L worked 6a to 2p and 2p to 10 p At 2:28 p.m. CNA M worked 2p to 10 p At 2:41 p.m. CNA N worked 2p to 10 p At 3:05 p.m. CNA O worked from 2p to 10 p At 3:58 p.m. LVN P At 4:12 p.m. LVN Q worked form 10 p to 6 a At 4:20 p.m. LVN R worked form 10 p to 6a At 4:26 p.m. RN C worked 2p to 10 p At 4:37 p.m. worked 6a to 2 p Interviews with nurses indicated they were knowledgeable about the in-services provided regarding residents being assessed in a timely manner. Contacting the physician and documenting the residents change in the facility computer system. Interviews with nurse aides indicated they were knowledgeable regarding reporting a change in condition and if the nurse did not act, they would notify the immediate supervisor. They were also knowledgeable about documenting the change in the facility computer system. During an interview on 3/13/14 at 2:47 p.m. the Administrator said she worked at the facility for about two years. She said the incident with Resident #1 was not reported to her. She said they were all surprised the resident had gone to the hospital and passed away but did not think there were any issues at the facility regarding the Resident. She said if a resident admits, discharges, or passed away it was communicated in the morning meetings. She said they were going to train and educate and complete more monitoring of staff actions. She said they will conduct a more in depth review in the clinical meeting, we will tackle problems that they find or that are brought to their attention. During an interview on 3/13/24 at 4:59 p.m. the DON said nurses should use common nursing judgement in some situations. She said they will make sure these things did not happen going forward. The DON said nurses were in serviced and reminded of things they should already be doing. She said daily she would print out order list to monitor and print out vitals daily just to look over. The DON said the aides were also in serviced and reminded of things they should have already been doing. She said the stop and watch alert is not new. She said all staff are aware if there was a change in condition with a resident to report it and if no action is taken go to the next level. She said they are to contact the NP or physician when they have questions about order clarification and change of resident condition in a timely manner. She said nurses were in serviced on the importance of physician notification. The Administrator, and DON were informed the IJ was removed on 3/13/24 at 5:23 p.m.; however, the facility remained out of compliance with a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure treatment and care was provided to meet professional standards of practice for 1 of 7 residents reviewed for quality of care. (Resident #1) The facility failed to ensure Resident #1 was provided a timely assessment when she experienced a change of condition. LVN A noted Resident #1 had a change in condition on 02/09/24 around 2:00 p.m. but LVN A did not assess the resident at that time. At 8:00 p.m., Resident #1's oxygen level was 87 percent and she had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. The resident was intubated and placed in ICU. An Immediate Jeopardy (IJ) was identified on 03/12/24. The IJ template was provided to the facility on [DATE] at 1:05 p.m. While the IJ was removed on 03/13/24, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of not being assessed for a change of condition that may require treatment alterations and could lead to additional pain and suffering. Findings included: Record of Resident #1's face sheet dated 3/5/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were congestive heart failure, bipolar disorder, schizoaffective disorder (mental health disorder including symptoms such as hallucinations, delusions, disorganized thinking, mania, and depression), dementia, and lack of coordination. Record review of Resident #1's admission MDS dated [DATE] indicated moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident required partial to moderate assistance with hygiene showers, upper body dressing, lower body dressing. The resident required partial to moderate assistance with transferring from chair to bed and toilet. Record review of Resident #1's care plan dated 1/5/24 indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were: Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia (side effect of antipsychotic medications that cause involuntary movements of the head and body including lip smacking, grimacing, eye blinking, and repetitive movements), seizures, and cardiac changes. Record review of Resident #1's nursing note indicated: On 2/8/24 at 1:41 p.m. resident continued to be very sleepy, did not wake up to take meds and ate 30 percent of lunch. She was in the wheelchair in the hallway sleeping. Her vital signs were stable. On 2/9/24 at 5:09 a.m. the resident was in bed with eyes closed easily arouse with respirations even and unlabored. No shortness of breath noted discontinued Venlafaxine HCL day three no adverse reactions. No signs and symptoms of sedations. The residence behavior within normal limits. No pain or discomfort observed. At 8:50 a.m. the resident blood pressure medications metoprolol and lisinopril were held due to blood pressure of 93/51. At 8:34 p.m. medications were held due to residence status. At 8:50 p.m. the resident was sent to the hospital due to change in condition. (There were no other notes or assessments.) Signed by LVN A Record review of Resident #1's EMS report dated 2/9/24 indicated arrived at the scene at 8:33 p.m. Upon arrival at the scene the patient was lying in bed, mumbling, and reaching aimlessly into the air. The patient could tell us her name and the staff (LVN A) stated she was a [AGE] year-old female, and she started acting strangely at approximately 2:00 p.m. The patient was placed on monitor and vitals were obtained her temperature was 100.6 Fahrenheit. blood pressure was 92/61, respirations were 18 and labored and her oxygen stat was 93 percent. The sounds in her lungs revealed bubbling and gurgling. She was given a nebulizer treatment which improved her lung sounds and was placed on 15 mL of oxygen via facemask. The patient was transported to the ER and arrived at the destination at 9:15 p.m. The chief complaint was, altered consciousness, and lethargy (unusual decreased consciousness) for at least six hours and fever. Record review of Resident #1's emergency hospital records dated 2/9/24 with the arrival time of 9:20 p.m. indicated the patient was found in respiratory distress, low blood pressure and rapid heartbeat. On arrival the patient was in respiratory distress on a non-breather mask at 15 L oxygen. The nurses at the nursing home stated there was a possible aspiration (when food, liquid, vomit, or foreign object enters the lungs) episode today. Her blood pressure was 124/68, her pulse was 142, her temp was 103, her oxygen stat was 94%. The diagnosis was sepsis (the body's response to an infection or widespread inflammation) secondary to pneumonia. The patient will be transferred to an ICU for further management due to the complexity of the case and being a full code. Patient received from a nursing home with respiratory distress with a stat of 87 per nursing home. Staff said the condition noted at 2:00 p.m. The patient vomited around that time. She was transferred to the hospital on 2/10/24 at 2:00 a.m. Record review of Resident #1's hospital records indicated the resident was admitted to their facility on 2/10/24 on arrival she was on 12 L nasal cannula and unresponsive with blood pressures in the 80 systolic and O2 stats in the 80s. She was emergently intubated (to establish an airway and prevent secondary brain injury). During an interview on 3/5/24 at 3:36 p.m. the DON said she received a message from LVN A on the night of 2/9/24. She said LVN A sent Resident #1 to the ER because she was not acting herself. The DON said LVN A said she contacted NP F and she said to send Resident #1 out. The DON said LVN A said Resident #1 did not eat supper and looked like she vomited something black. The LVN said Resident# 1's O2 stat was at 87 percent. The DON said the facility Interact transfer form was not in the clinical record and there was nothing in the nursing notes about Resident #1's condition prior to hospitalization. The DON said from what she saw in Resident #1's clinical record LVN A did not make the clinical document, she had likely assessed Resident #1 because she told her the blood pressure and oxygen status, but she did not document anything. During an interview on 3/5/24 at 5:05 p.m. RN C said Resident #1 had a steady decline. She said Resident #1 would repeat things over and over and over and sit in the hallway and yell out. She said the doctor put Resident #1 on Venlafaxine to aide with her behaviors. RN C said Resident#1 had been a lethargic for several days, the medications were reduced and discontinued. She said on 2/9/24 Resident #1 was sitting at the assisted dining table and refused to eat. The RN said Resident #1 appeared to be lethargic. She said Resident #1 would not wake up, and just blink, that was all. The RN said she was the one who tried to assist Resident #1 to eat and when she tried to put something in her mouth, she would not respond. She said the Resident #1 did not appear to be with it enough to chew. The RN said she was afraid Resident #1 would choke so she refused to feed her. She said she was not her nurse but had observed the resident was not her usual self for several days, and she was just assisting in the dining room. RN C said she thought Resident #1 was just having symptoms from the medications. During an interview on 3/5/24 at 5:07 p.m. LVN G said Resident #1 had been sleepy for the last couple of days. She said she worked with the Resident #1 the day before she was hospitalized on [DATE] and the Resident seemed fine. She said Resident #1's vitals were within normal limits for Resident #1. She said Resident #1 was not coughing or wheezing and had no rattle. The LVN G said Resident #1's voice was raspy as always but not wet. She said the Resident #1 was put on some new medications because she would sit in the hallway and yell and scream. The LVN said when most residents that are put on the medications, they are usually sleepy the first few days. She said there were some changes with the Venlafaxine and it was discontinued. She said she administered the medication as prescribed. She said Resident #1 would wake up and respond when spoken to. During an interview on 3/5/24 at 5:11 p.m. CNA B said she worked at the facility for about 1 year. She said when Resident #1 first arrived at the facility she would repeat things over and over. She said Resident #1 had a moderate decline. She said she was at the facility on 2/9/24 when Resident #1 was sent to the hospital. She said when she arrived that day at 2:00 p.m. Resident #1 could hardly do anything. She said Resident #1 was just sitting in the wheelchair with her head back and appeared to be asleep but was hard to awaken. She said it was like Resident #1 could not hold her head down at all. CNA B said Resident #1 had been kind of out of it (real sleepy and not herself, but she would respond) for the last couple of days, however on that day she would barley respond. She said all the nurses were aware the resident had a decline; Resident #1 would usually be placed right in front of the nurses' station. CNA B said the nurses said Resident #1 was like that because some medication they had put her on made her sleepy. CNA B said Resident #1 would not eat supper on 2/9/24, she would not open her mouth or hold her head down to take a bite. She had informed LVN A Resident #1 could not eat. She said that night around 8:00 p.m. when she was putting Resident #1 to bed, she had some black stuff coming out of her mouth and she told the nurse. CNA B said it was at that time the LVN A came and looked at Resident #1 and sent her out to the hospital. During an interview on 3/11/24 at 11:20 a.m. the DON said she saw LVN A but did not talk to her about Resident #1. She said she thought the LVN could not complete a note or an assessment after the Resident #1 was deceased . The DON said it appeared LVN A came in at 2p on 2/9/24 and failed to assess the resident when a change in condition was noted or to document what was going on with Resident #1. During a telephone interview on 3/11/24 at 11:25 a.m. LVN A said when she came to work on 2/9/24 at 2:00 p.m. Resident # 1 was in her wheelchair asleep and had her neck/head back. She said Resident #1 was usually up talking but she was not her normal self. She said when they went to supper the resident did not eat anything. She said around 8:00 p.m. she texted NP F and she told her Resident #1 need to be sent out. She said she texted the physician at the same time around 8:00 p.m. The LVN said she checked her vital signs and everything. She said she did not remember if she had written anything down or not. She said she worked PRN and did not know what was going on with Resident #1. She said she assessed her but did not complete the assessment because she did not have time. She said after they laid Residen t#1 down that night her breathing was shallow and her 02 sat was under 90. She said Resident #1 was laying in the bed reaching in the air. The LVN said Resident #1 did not have a fever and EMS did not say anything about her breathing. During an interview on 3/11/24 at 11:44 a.m. NP F said she felt the nurses were good about reporting things, and she received mixed messages about Resident #1. She said one nurse would report one thing and one nurse would see something different. She said she had reports that Resident #1 would eat good one day and one day not. She said the reports that she received about Resident #1 were not consistent. She said she was shocked when they reported the resident had died, it was totally unexpected. On 2/9/24 at 8:04 p.m. she received a text from LVN A. She said the text stated Resident #1 was not acting herself, 02 stat was 87 at the time, bp was 117/78, and heart rate 67. NP F said Resident #1 was started on a high dose of Venlafaxine because she appeared to be able to tolerate high doses of medications. She said everyone was different, they held it, decreased it, watched it, and discontinued the medication. She said she was not aware if anyone called her to restart the medications or when she told the staff to start Resident #1 back on the Venlafaxine. However, from the calls she had received the resident did not tolerate the medications well and she had discontinued it on 2/7/24 due to reports of continued lethargic behaviors. She said she did want Resident #1 to be monitored for low blood pressure and fever for drug interactions with the Venlafaxine and Resident #1's current medication for possible serotonin overdose. She said the Serotonin Syndrome had several different symptoms and could cause a resident medical distress. She said that was why she wanted the resident checked for fever and low blood pressure. She did not know that those checks did not appear to be done. She said she had gotten some calls from LVN G and RN D about Resident #1 but no acute calls. During an interview on 3/11/24 at 12:00 p.m. RN D said she had worked with Resident #1 the day before she had gone to the hospital. She said Resident #1 was sleepy but would respond. She said other than being sleepy she was her normal self. She said the resident did not have a cough and had taken her medications without incident. She had eaten only part of her lunch that day, but she did not note any distress. During an interview on 3/11/24 at 12:05 p.m. CNA H said when she arrived at the facility on 2/8/24 at 6:00 a.m. She said Resident #1 was extremely hard to get up that morning. She said Resident #1 seemed overly tired. She said Resident #1 was less coherent. CNA H said normally Resident #1 wanted to go out to smoke or go to the dining room to wait on breakfast but said did not want to do any of those things. She said for the last few days Resident #1 would sleep quite a bit. She said most days she would sleep some because she may have been up the night before. She said on that day she was sleeping and not eating. CNA H said RN D was the nurse on 2/8/24 and she knew Resident #1 was more tired than usual because she had told her. She had also placed the resident close to the nurse's station. During an interview and record review on 3/11/24 at 3:40 p.m. the DON said review of the EMS and hospital records indicated LVN A had told the hospital Resident #1 had a change in condition around 2:00 p.m. The DON said she was not made aware of the change until around 8:00 p.m. She could not say why the nurse had waited 6 hours before assessing Resident #1 and sending her out to the hospital. During a telephone interview on 3/11/24 at 3:50 p.m. LVN A said she told the hospital the Resident #1 had thrown up at about 2:00 p.m. and it was black. They had chocolate cake but she did not know if it was the cake or not. She also told the hospital Resident #1 had a change in condition around 2p. During an interview on 3/12/24 at 9:41 a.m. the NP F said there were no reports of any changes with Resident #1 until around 8:00 p.m. on 2/9/24. During an interview on 3/12/24 at 10:01 the BOM said the family member texted her the day Resident #1 went to the hospital to say she seemed over medicated they could not get her to wake up. She said she had told the nurse. The family member had texted her again, but she did not recall exactly what the text said. During a telephone interview on 3/12/24 at 10:30 a.m. a family member said on the day Resident #1 went to the hospital her family member called her crying and upset because Resident #1 could not seem to get her breath to talk. That Family member said they were there on 2/9/24 about 2 or 3 in the afternoon. The family member said whoever she talked to told her Resident #1 had been like that for two or three days. The family member said Resident #1 was sitting in the wheelchair with her head back and she could not get her to really wake up. The family member said Resident#1 had a bruise on her face that looked like it was a few days old. The aide told her the resident had fallen in her room a few days earlier. The family member said they wheeled Resident #1 out by the nurse's station because they were concerned, she was not doing well. The family member said they talked to the nurse behind the nurse's station and asked what was going on with Resident#1? The family member said she did not really get an answer and was upset and confused when she left the facility. She thought something was wrong, but the staff acted like Resident #1 was fine, but she was not. The family member said the Resident had black stuff coming out of her mouth. She said they could not get her head down so she could clean her mouth, it looked like she had food in her mouth. They said Resident #1's neck was in almost an awkward position held back and she did not appear to be able to lift her head. The family member said when Resident #1 arrived at the hospital food was stuck to the top of her mouth, and it was so bad they had to throw the dentures away. The food looked like it had been there for a long time. The family member said the Resident #1's neck was held in a back position when she was in the hospital even while lying in the bed. It was like her neck was paralyzed in that position. During an interview on 3/13/24 at 1:21 p.m. CNA K said Resident #1 was not herself at all. She said some nurses they reported to would act and others would not. She said Resident #1 had a tremendous change. She was loud and very vocal. They changed her medications, and she was zonked out, sleeping like she was not in the world. She said they reported their concerns to the nurses, and they would say it was just the medication. CNA K said the last 3- or 4-days Resident #1 was in the facility, it did not matter if Resident #1 was up in the chair or in bed her head was back, her mouth was open, and she was asleep. During an interview on 3/13/24 at 1:45 p.m. RN D said she was thinking Resident #1's problem was the change in medications. She had seen her in the hallway picking things out of the air and she was still asleep. She said she had not really assessed her but if someone told her black stuff was coming out of her mouth, she would have assessed her for sure. During an interview on 3/13/24 at 4:26 p.m. RN C said she was not Resident #1's nurse on 2/9/24. She said at dinner she tried to feed Resident #1, and she could not eat. The RN said she refused to feed Resident #1 and told the aide not to even try. She said it appeared Resident #1 was unable to hold her head down to eat. She sat with her head back like she was asleep and was not responding appropriately at all. She said LVN A was in the dining room and heard the interactions about Resident #1 not being able to eat dinner. RN C said after the Resident #1 had gone to the hospital and LVN A asked if she had feed the resident anything. She said LVN A said something was coming out of Resident #1'smouth. RN C said Resident #1 had a change in condition, she was sleeping and could not be awaken, her head was back, and she could not eat. She said she asked the DON today what she should have done? She said Resident #1 was not her resident, and she noted a change in condition. LVN C said the DON told her if the other nurse did not assess the resident, then she needed to assess, make all the necessary calls and documentation. Record review of the facilities change in a resident condition or status policy, last revised May 2017, indicated our facility shall promptly notify the resident attending physician changes in the resident medical condition. The nurse will notify the resident attending physician on call when there has been a significant change in the resident, physical, emotional, or mental condition. A significant change of condition is a major decline or improvement, in the resident status that will not normally resolve itself without intervention impacts more than one and impacts more than one area of the resident health. Prior to notifying the physician or healthcare provider the nurse will make detail observations and gather relevant pertinent information for the provider, including for example, information provided by the in-communication form, the nurse will record in the resident record information relative to changes in the resident medical mental condition or status. The Administrator was notified on 03/12/24 at 1:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 03/12/24 at 1:05 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 03/13/24 at 11:12 a.m. and included: [Plan of Removal F-684 Action: The Director of Infection Prevention will provide education on company's policy related to assessment of a resident when they experience a change of condition to the DCO. 3/12/2024 The employee that failed to follow the facility policies regarding parameters will receive not only the education outlined below, but will also receive disciplinary action. In-service on company's policy related to assessment of a resident when they experience a change of condition to all nurses conducted by the DCO/Designee. A copy of the inservice regarding change of condition will be provided for review. The policy and procedure outlines examples of occurrences that would necessitate notification of a change of condition. If an aide reports a change in condition, the nurse is expected to evaluate the resident and make a determination of necessary additional treatment. The facility assessment form will be completed when residents are sent to the hospital. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by 3/13/2024. This education will also be included in all new nurse orientation for any newly hired nurses. Nurse aides were re-educated on utilization of the Stop and Watch notification in Point Click Care for changes in condition on 3/13/24. Nurses were educated on reviewing the PCC dashboard for the automatically triggered alerts with visual demonstration on 3/13/24. DCO/Designee to complete chart reviews daily during the clinical meeting to ensure thorough and accurate assessments are completed when a resident experiences a change of condition per policy. 3/12/2024. In reviewing resident charts, the DCO or designee will monitor for occurrences such as medication changes, falls and resident discharges to the ER. A chart audit was conducted by the DCO/Designee on 3/12/24 to see if any residents experienced a change in condition that required assessment. No additional concerns were identified. The Medical Director has been notified of the immediate jeopardy and reviewed current policy and procedures assessment of a resident when experiencing a change of condition. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with assessments of residents who experience a change of condition per policy and procedures. 3/12/2024 ] On 03/13/24 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the staff disciplinary actions indicated they were completed. Review of the Chart audits on medications indicated they were completed and all residents on blood pressure medications had parameters in place. Review of the medication competencies on medication pass were completed for the staff that were present. Review of disciplinary action for LVN A dated 3/13/24 indicated the employee had failed to notify the physician and provide an assessment for a resident prior to hospitalization. The employee will follow facility policy regarding physician notification and assessing a resident when they have a changing condition. The first employee will timely and accurately document all the Above in the computer system. Any future violations of this policy will result in termination. The form indicated spoke to the employee on the phone and she will be signed up upon return to work. Interviews were conducted with facility staff on 3/13/14 between 12:59 p.m. and 4:59 p.m. At 12:29 p.m. CNA I worked 6a to 2p At 1:07 p.m. CNA J worked 6a to 2p At 1:21p.m. CNA K worked 6a to 2p and 10 p to 6a At 1:45 p.m. RN D worked 6a to 2p At 2:16 p.m. LVN L worked 6a to 2p and 2p to 10 p At 2:28 p.m. CNA M worked 2p to 10 p At 2:41 p.m. CNA N worked 2p to 10 p At 3:05 p.m. CNA O worked from 2p to 10 p At 3:58 p.m. LVN P At 4:12 p.m. LVN Q worked form 10 p to 6 a At 4:20 p.m. LVN R worked form 10 p to 6a At 4:26 p.m. RN C worked 2p to 10 p At 4:37 p.m. worked 6a to 2 p Interviews with nurses indicated they were knowledgeable about the in-services provided regarding residents being assessed in a timely manner. Contacting the physician and documenting the residents change in the facility computer system. Interviews with nurse aides indicated they were knowledgeable regarding reporting a change in condition and if the nurse did not act, they would notify the immediate supervisor. They were also knowledgeable about documenting the change in the facility computer system. During an interview on 3/13/14 at 2:47 p.m. the Administrator said she worked at the facility for about two years. She said the incident with Resident #1 was not reported to her. She said they were all surprised the resident had gone to the hospital and passed away but did not think there were any issues at the facility regarding the Resident. She said if a resident admits, discharges, or passed away it was communicated in the morning meetings. She said they were going to train and educate and complete more monitoring of staff actions. She said they will conduct a more in depth review in the clinical meeting, we will tackle problems that they find or that are brought to their attention. During an interview on 3/13/24 at 4:59 p.m. the DON said she completed chart audit, regarding blood pressure medications and went through to see who had parameters. She said they audited new orders on medications. The DON said residents that did not have blood pressure have parameters they put those in place. Had one resident had 120/80 as a blood pressure parameter and clarified with the doctor. She said she completed medication administration competency with nurses that have been in the building. The DON said nurses should use common nursing judgement in some situations. She said they will make sure these things did not happen going forward. They had implemented standing orders, for blood pressure medications. The DON said nurses were in serviced and reminded of things they should already be doing. She said daily she would print out order list to monitor and print out vitals daily just to look over. The DON said the aides were also in serviced and reminded of things they should have already been doing. She said the stop and watch alert is not new. She said all staff are aware if there was a change in condition with a resident to report it and if no action is taken go to the next level. The Administrator and DON were informed the IJ was removed on 3/13/24 at 5:23 p.m.; however, the facility remained out of compliance with a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 2 of 7 residents reviewed for medications. (Resident #1 and Resident #2) The facility failed to ensure: *Resident #1 (deceased ) was given medications as prescribed. She was given Venlafaxine 75mg two times daily for a total of 6 times over a period of 5 days when the medication was supposed to be on hold. *Resident #1 was given Lisinopril and Metoprolol Succinate ER 12 times in [DATE] and 3 times in February 2024 when the medications were supposed to be held because her blood pressure was below the parameters. *Resident #1's orders were followed due to the possible interactions of Venlafaxine, with Tramadol, Ibuprofen and other medications Resident #1 was receiving. The NP said to monitor for low blood pressure and fever due to Serotonin syndrome. There was no indication this monitoring was provided. *Resident #2 (a current resident) Carvedilol 3.125 mg blood pressure medications given in [DATE] times when her blood pressure was below the parameters. *A system in place to ensure the medications were held and medication parameters were followed. *Their medication administration policy was followed. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:05 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of physical complications, hospitalization, and possible death. Findings included: Record of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were congestive heart failure, bipolar disorder, schizoaffective disorder (mental health disorder including symptoms such as hallucinations, delusions, disorganized thinking, mania, and depression), dementia, and lack of coordination. Record review of Resident #1's admission MDS dated [DATE] indicated moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident required partial to moderate assistance with hygiene showers, upper body dressing, lower body dressing. The resident required partial to moderate assistance with transferring from chair to bed and toilet. Record review of Resident #1's care plan dated [DATE] indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were: Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia (side effect of antipsychotic medications that cause involuntary movements of the head and body including lip smacking, grimacing, eye blinking, and repetitive movements), seizures, and cardiac changes. Record review of Resident #1's care plan dated [DATE] indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were:. Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia, seizures, and cardiac changes. Record review of Resident #1's physician orders indicated in order dated [DATE] for lisinopril tablet 2.5 mg to given by mouth one time a day for hypertension hold if the systolic blood pressure is under 100 or the diastolic blood pressure is under 60. An order Metoprolol Succinate ER 25mg tablet extended release 25 mg give one tablet by mouth in the morning for hypertension is systolic is less than 110 and diastolic is less than 60 or post is less than 60. Record review of Resident #1's MAR for [DATE] indicated the resident's lisinopril and metoprolol were given on these dates when her blood pressures were below the parameters. On [DATE] A blood pressure of 92/48 On [DATE], a blood pressure of 98/87 On [DATE] a blood pressure of 97/7 On [DATE], a blood pressure of 93/58 On [DATE], a blood pressure of 110/58 On [DATE], blood pressure 127/58 On [DATE], a blood pressure of 123/53 On [DATE] a blood pressure of 112/51 On [DATE] a blood pressure of 105/51 On [DATE] a blood pressure of 126/52 On [DATE] a blood pressure of 94/52 On [DATE] a blood pressure of 108/53. Record review of Resident #1's February 2024 MAR indicated the resident's lisinopril and metoprolol were given on these dates when her blood pressures were below the parameters. On [DATE] a blood pressure of 103/58 On [DATE] a blood pressure of 112/54 On [DATE] a blood pressure of 142/59 During an interview on [DATE] at 1:02 p.m. the DON said the checks on the MAR meant the medications were given. The DON said according to the documentation all the blood pressure medications were given on the dates when the blood pressure was below the parameters. She said a 5 means hold, 9 means progress notes. She said that was not their procedures or good nursing judgement to give blood pressure medications when the blood pressure was below the parameters. She did not know why they were given but they were all given by RN D. During an interview on [DATE] at 1:15 p.m. RN D said she did not remember if she held Resident #1's the blood pressure medications or not. She said she would have thought she had not given them but could not be sure. She said she knew if she checked that she gave them then she gave them. Record Review of Resident #1's computerized physician order indicated orders for: Depakote 125 mg 4 tablets three times daily for behaviors ordered [DATE]; Risperdal 2mg one tablet at bedtime for bipolar disorder ordered [DATE]; Ibuprofen 800 mg every 8 hours as need for pain ordered [DATE]; Tramadol 50mg give one tablet two times a day for pain ordered [DATE]; Buspirone HCL 5mg 2 tables three times daily for anxiety ordered [DATE]. Resident' #1's February 2024 MAR indicated an order dated [DATE] for Venlafaxine 75 mg two times a day for increased mood discontinued on [DATE]. Record review of Resident #1's nurses notes dated [DATE] indicated: At 10:24 a.m. an order noted the Venlafaxine HCL has triggered the following drug protocol alerts and warnings related to drug-to-drug interaction. The system has identified a possible drug interaction with current medications such as Ibuprofen 800 mg may increase the risk of upper gastrointestinal bleeding. Buspirone 5mg table interaction additive serotonergic affects ( may increase serotonin levels). Tramadol 50 mg at risk for developing serotonin syndrome ( potentially life threating condition associated with activity in the central nervous system. Usually caused by interactions between drugs). At 10:28 a.m. the resident was seen by NP E today and indicated to start Venlafaxine 75 mg by mouth two times a day to increase mood and decrease depression and agitation. At 3:52 p.m. the resident was seen by NP F who said to monitor the resident for acute signs and symptoms of fever and low blood pressure.( There was no indication this recommendation or order was followed. ) signed by the ADON. Record review of Resident #1's [DATE] MAR indicate indicated the resident received Venlafaxine 75 mg on [DATE] at 7p.m. and on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m . Record review of Resident #1's nursing note dated [DATE] at 1:40 a.m. indicated the resident was resting quietly in bed. At 11:32 a.m. the resident was given venlafaxine per order. Record review of Resident #1's nursing note dated [DATE] at 10:29 a.m. indicated the resident was very sedated sitting up in wheelchair with eyes closed, reaching for things that were not there. NP F was notified and received an order to hold Venlafaxine 75 mg until the resident is back to baseline. Then MD and NP to adjust dosage MAR updated. Record review of Resident #1's nursing note dated [DATE] at 8:40 p.m. indicated Ibuprofen 800 mg given for pain, with complaints of hurting all over . (Record review of Resident #1's orders did not reveal an order to hold the medications, or to restart the medications.) Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. It was not given at 7:00 p.m. and indicated it was on hold. Record review of Resident #1's nursing note dated [DATE] at 11:30 a.m. resident up in wheelchair , more alert today, propelling self-short distances, no complaints of discomfort. At 8:34 p.m. Venlafaxine 75 mg on hold. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was not given at 7:00 a.m. and not given at 7:00 p.m. the MAR indicated the medication was on hold. Record review of Resident #1's nursing note on [DATE] at 8:32 a.m. indicated Venlafaxine 75 mg remains on hold. At 9:29 a.m. called to the resident room by CNA. The resident noted laying on her abdomen on the floor. She stated she was trying to get out of bed. The resident was assessed for injuries. Vital signs within normal limits the resident was assisted back to bed by two staff members, there were no injury noted. Encourage the resident to wait for assistance to get out of bed. At 1:16 p.m. Resident up at nurses' station, alert and oriented answers questions appropriately denies pain or discomfort, no delayed injuries notes post fall thus far and neuro checks remain within normal limits. At 9:19 p.m. Venlafaxine 75 mg remains on hold. At 10:51 p.m. Ibuprofen 800 mg given for pain with complaints of hurting all over. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on day three, and she had an unwitnessed fall with no injury. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m. Record review of Resident #1's nursing note on [DATE] at 1:07 a.m. the resident is resting quietly in bed, easily aroused respirations even and unlabored with no shortness of breath noted. She had reddened areas to the right side of face that reddened. There are no delayed injuries noted from the fall. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold- day 4 and she received ibuprofen for complaints of pain. Record review of Resident #1's MAR for February 2024 indicated on [DATE] the MAR indicated see progress note. Record review of Resident #1's nursing note on[DATE] at 8:39 a.m. Venlafaxine 75 mg two times a day held until clarified. At 11:02 a.m. received a new order for Venlafaxine 37.5 mg daily the updated pharmacy notified. At 11:02 a.m. NP F gave an order to decrease Venlafaxine to 37.5 mg. MAR updated and pharmacy notified. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold 6a to 2p nurse to get clarification. Record review of Resident #1's physician orders dated [DATE] indicated an order for Venlafaxine 37.5 give one tablet one time a day for anxiety. It was discontinued on [DATE]. Record review of Resident #1's nursing note dated [DATE] at 1:25 a.m. indicated the resident is awake, naps on and off, talking at random, repeating phrases over and over, speech is clear. To restart Venlafaxine 37.5 for depression. At 5:42 a.m. the resident was awake all night, talking out at random. Record review of Resident # 1's MAR indicated she received Venlafaxine 37.5 mg at 8 AM. The MAR indicated the medication was discontinued on [DATE]. Record review of Resident #1's nursing notes dated [DATE] at 11:18 a.m. Venlafaxine given per order. At 5:18 p.m. resident sitting in wheelchair, unable to stay awake for very long. Lethargic and oriented times one. NP F was notified of residents change in orientation and requested Venlafaxine be discontinued due to medication interaction. At 8:19 p.m. The resident was lethargic and refused to wake up to take medications. The resident was responding appropriately to self. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 37.5 mg. On the night shift resident awake all shift. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine discontinued. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine discontinued day two. The resident sent to the hospital at 8:49 p.m. due to changing condition. During an interview on [DATE] at 11:44 a.m. NP F said Resident #1 was started on a high dose of Venlafaxine because she appeared to be able to tolerate high doses of medications. She said everyone was different, they held it ,decreased it, watched it, and discontinued the medication. She said she was not aware if anyone called her to restart the medications or when she told the staff to start Resident #1 back on the Venlafaxine. However, from the calls she had received the resident did not tolerate the medications well and she had discontinued it on [DATE] due to reports of continued lethargic behaviors. She said she did want Resident #1 to be monitored for low blood pressure and fever for drug interactions with the Venlafaxine and Resident #1's current medication for possible serotonin overdose. She said the Serotonin Syndrome had a several different symptoms and could cause a resident medical distress. She said that was why she wanted the resident checked for fever and low blood pressure. She did not know that those checks did not appear to be done. She said she had gotten some calls from LVN G and RN D about Resident #1 but no acute calls. During an interview and record review on [DATE] at 2:21 p.m. The ADON said she had not written an order when NP F told indicated Resident #1 needed to be monitored for fever and low blood pressure, she had just put in as nursing note. She said the nurses were supposed to monitor for adverse reactions when giving give new medications anyway. She said that NP recommendation was supposed to be on the 24-hour report. After review of the 24-hour reports, she acknowledged that it was not noted on the reports. The ADON said she was no sure if she talked to the NP F or if she just put a note on her desk. She said they did not have an official system in place for recommendations to be added to the MAR. sShe said she had not placed an order in the computer. The ADON said it was good nursing practice to not give blood pressure medications if the diastolic blood pressure was below 60 even without stated parameters. She did not know why a nurse would give the medications. During an interview and record review on [DATE] at 3:40 p.m. the DON said there was no order to put Venlafaxine on hold. Review of Resident #1 's MAR revealed the Venlafaxine was given when it was supposed to be on hold. She said she did not know why some staff gave the Venlafaxine and some did not. She said normally they put in an order to hold medications for a specific time and did not know why that had not occurred . She said they would put it in the nurses notes and on the 24-hour report to remind nurses of the hold. Review of the nurses' notes indicated some nursesd did document the Venlafaxine was on hold and it was on the 24-hour report however it was still given when it was supposed to be on hold. She said they had a system in place but apparently it did not work for Resident #1. During an interview on [DATE] at 9:34 a.m. the DON said the Venlafaxine should have been put on hold in the computer with a clarification of how long it was on hold. The DON said nurses are to clarify orders if there is are any questions. She said the physician should have been notified more frequently of Resident change in condition. She said they should have put the information into computer system and it should have had a timeframes. She said in order to fix the situation they needed to monitor orders, monitor MARs and provide training for nurses. During an interview on [DATE] at 9:41 a.m. the NP F said she had no knowledge Resident #1 was still getting Venlafaxine when it was supposed to be on hold. She said she had assumed that they her order in the system and they were following it as recommended. She said with the blood pressure medications nursing judgment would be to hold the blood pressure medications according to parameters. Resident #2 Record review of Resident #2's face sheet dated [DATE] indicated she was admitted to the facility on [DATE]. Some of her diagnoses were essential primary high blood pressure, and a history of stroke. Record review of Resident # 2's care plan dated [DATE] indicated a Focused area of complications related to high blood pressure and at risk for side effects of medications. Interventions were to monitor blood pressure for side affects of medications. Record review of resident #2 Physicians orders indicated carvedilol 3.125 mg give one tablet by mouth two times a day for hypertension hold if systolic blood pressure is less than 100 or diastolic is less than 60 or heart rate is 55. Record review of resident #2 MAR for [DATE] indicated: On [DATE] at 8:00 a.m. blood pressure was 111/57. On /11/24 at 8:00 a.m. blood pressure was 91/59 On [DATE] at 8:00 p.m. blood pressure was 101/46. During an interview and record review on [DATE] at 9:15 a.m. Review records with the DON was shown showed Resident #2 record a resident with high blood pressure. The records revealed she received blood pressure medications and had parameters for those medications. Her blood pressure medications were given three times in [DATE] when her blood pressure was below the parameters. The DON said two of those times were by RN D. During an interview on [DATE] at 1:01 p.m. the DON said if a resident is given blood pressure medication and their blood pressure is already low it could cause them to be lightheaded and fall or it could cause the residents blood pressure to bottom out and they go into cardiac arrest and die . Record review of the facilities guidelines for medication administration policy with the revision date of eight 2022 indicated medication's are administered as prescribed in accordance with good nursing practices and practices that only legally authorize to administer medication in preparation always employed the more during medication administration prior to the administration of any medication, the medication and dosage schedule on the residence March are compared with the medication label if the label in the mark are different and the container has not already been flagged, indicating a change in instructions or there is any other reason to question the doses or directions, the physicians orders are checked for the correct dosage schedule when a medication ordered is changed, and the remainder of the current supply can still be used. The complaint container should be flagged right away in order changed communicated to the provider pharmacy. The administration of medication indicates medication's are in administered in accordance with written orders of the prescriber. Monitoring of side effects or medication related problems occurs but particularly after medication is administered and especially after the first few doses of a medication documentation, including electronic indicated if an electronic system is used, specific procedures, required for resident, identification, identification of medication, due to specific times, and documentation of administration, refusal, holding of doses, and dosing parameters, such as vital signs and lab values are described in the systems user manual. These procedures should be followed, and made for slightly from the procedures for using paper mars. Electronic systems. Also describe procedures for secure access, maintaining privacy of resident information, and for electronic signatures. The Administrator was notified on [DATE] at 1:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:05 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] at 10:09 a.m. and included: [Plan of Removal F-757 Action: The Director of Infection Prevention will provide education on company's policy related to medication administration including following physician-ordered medication parameters were followed to the DCO. [DATE] The DCO or designee will clarify any orders that require clarification upon review. If a medication is noted on the 24 hour report to be on hold, the DCO or designee will ensure that this is reflected in the residents physician orders. The employee that failed to follow the facility policies regarding parameters will receive not only the education outlined below, but will also receive disciplinary action. In-service on company's policy related to medication administration including following physician-ordered medication parameters to all nurses conducted by the DCO/Designee. The inservice will be a reminder for most, but it will be in-depth in reviewing the negative outcomes that a resident could experience as a result of failing to observe the parameters. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by [DATE]. This education will also be included in all new nurse orientation for any newly hired nurses. DCO/Designee to complete chart reviews daily during the clinical meeting to ensure medication administration including following physician-ordered medication parameters are being carried out per policy. [DATE] A random audit was conducted on [DATE] and no additional residents were identified as affected. DCO/Designee to complete med pass competencies on all regularly scheduled nurses by [DATE]. Any part time or PRN staff that are unavailable to complete a competency by [DATE] will be required to do so prior to returning to work. The Medical Director has been notified of the immediate jeopardy and reviewed current policy and procedures for medication administration including following physician-ordered medication parameters. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with the medication administration policy and procedures. [DATE] ] On [DATE] the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the staff disciplinary actions indicated they were completed. Review of the Chart audits on medications indicated they were completed and all residents on blood pressure medications had parameters in place. Review of the medication competencies on medication pass were completed for the staff that were present. During an interview on [DATE] at 1:45 p.m. RN D said she did a general medication pass and competency on the blood pressure, and plus prior to administering medications. She said when she talked to NP F she just said until she reached baseline, and she did not give dates. The RN said had trouble with computers. She said she thought she put the order in but it did not appear to take. She said with the blood pressures looked like she gave them but she did not think that she had. She said she knew the charting said she did. Record review of a disciplinary action for RN D dated [DATE] indicated the employee failed to put a medication on hold per physician orders. Also the employee administered blood pressure medication to two different residence when it should have been held when the blood pressure was below the parameters. The employee will follow facility administration, policies, and corrective action taken. Any future policy violation will result in termination. The form indicated the employee will sign when she returns to work. Interviews were conducted with facility staff on [DATE] between 12:59 p.m. and 4:59 p.m. At 12:29 p.m. CNA I worked 6a to 2p At 1:07 p.m. CNA J worked 6a to 2p At 1:21p.m. CNA K worked 6a to 2p and 10 p to 6a At 1:45 p.m. RN D worked 6a to 2p At 2:16 p.m. LVN L worked 6a to 2p and 2p to 10 p At 2:28 p.m. CNA M worked 2p to 10 p At 2:41 p.m. CNA N worked 2p to 10 p At 3:05 p.m. CNA O worked from 2p to 10 p At 3:58 p.m. LVN P At 4:12 p.m. LVN Q worked form 10 p to 6 a At 4:20 p.m. LVN R worked form 10 p to 6a At 4:26 p.m. RN C worked 2p to 10 p At 4:37 p.m. worked 6a to 2 p Interviews with nurses indicated they were knowledgeable about the in-services provided regarding residents' medication administration. The nurses indicated they followed the parameters for administering blood pressure medications and were familiar with going into the system and putting medications on hold. They indicated when they go in to administer medications the system informed them when medications were due. If there was no hold order in the computer, they could have given the medications. The nurses also said if they received an order from the NP or the doctors they would read the order back for a clear understanding. If a doctor gave an order to hold the medications, they would ask for time frames and put them the computer. During an interview on [DATE] at 2:47 p.m. the Administrator said she worked at the facility for about two years. She said the incident with Resident #1 was not reported to her. She said they were all surprised the resident had gone to the hospital and passed away but did not think there were any issues at the facility regarding the Resident. She said if a resident admits, discharges, or passed away it was communicated in the morning meetings. She said they were going to train and educate and complete more monitoring of staff actions. She said they will conduct a more in depth review in the clinical meeting, we will tackle problems that they find or that are brought to their attention. During an interview on [DATE] at 4:59 p.m. the DON said nurses should use common nursing judgement in some situations. She said they will make sure these things did not happen going forward. The DON said nurses were in serviced and reminded of things they should already be doing. She said daily she would print out order list to monitor and print out vials daily just to look over. The DON said the aides were also in serviced and reminded of things they should have already been doing. She said the stop and watch alert is not new. She said all staff are aware if there is a change in condition with a resident to report it and if no action is taken go to the next level. She said they are to contact the NP or physician when they have questions about order clarification and change of resident condition in a timely manner. She said she had completed medication administration competency evaluations on nurses that had been in the buildings. The Administrator and DON were informed the IJ was removed on [DATE] at 5:23 p.m.; however, the facility remained out of compliance with a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.